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A 43-year-old HIV-infected woman presents to the clinic with oral candidiasis that is clinically not responding to fluconazole (Diflucan) 200 mg PO once daily. She has advanced immune suppression with a CD4 count of 22 cells/mm3 and HIV RNA of 46,340 copies/ml. She is taking a 5-drug salvage antiretroviral therapy regimen, trimethoprim-sulfamethoxazole (Bactrim, Septra), azithromycin (Zithromax), and fluconazole. She has taken fluconazole on and off for 6 months for recurrent bouts of oropharyngeal candidiasis and the past 3 months she had taken fluconazole 200 mg PO once daily. She currently denies any esophageal symptoms.

Which of the following is true regarding fluconazole-resistant oral candidiasis in HIV-infected patients?

The most important risk factor identified for the development of fluconazole-resistant oropharyngeal candidiasis is the use of trimethoprim-sulfamethoxazole (Bactrim, Septra) for longer than 60 days.

Incorrect

Although some antimicrobials increase the risk of patients developing oral candidiasis, there are no data to suggest trimethoprim-sulfamethoxazole use is directly related to the development of fluconazole-resistant candidiasis.

Fluconazole resistance in Candida species occurs primarily through an increase production in cell wall precursors.

Incorrect

The mechanism of action of fluconazole involves decreasing the synthesis of ergosterol, the key component of the fungal cell membrane. Specifically, fluconazole blocks a step in the conversion of squalene to ergosterol by inhibiting the fungal cytochrome P-450 enzyme 14 alpha-demethylase. Fluconazole does not have activity on fungal cell wall synthesis. Fluconazole resistance results from an alteration in the target enzyme 14 alpha-demethylase (change in binding site or over expression of the enzyme) or enhanced drug efflux caused by plasma membrane transporters. Many strains have developed multiple resistance mechanisms.

More than 95% of Candida albicans isolates from patients with fluconazole-refractory oropharyngeal candidiasis show resistance to itraconazole (Sporanox). Fewer than 5% of patients with fluconazole-refractory oropharyngeal candidiasis will respond to itraconazole solution at a dose of 200 mg per day.

Incorrect

Available data suggest more than 50% of patients with fluconazole-refractory oropharyngeal candidiasis will respond to itraconazole solution given at a dose of 100 to 200 mg per day.

Major identified risk factors for the development of fluconazole-resistant candidiasis include low CD4 cell count and cumulative fluconazole use.

Correct

The most important risk factors identified related to the development of fluconazole-resistant candidiasis include low CD4 cell count, greater number of fluconazole-treated episodes, and longer median duration of fluconazole therapy. Fluconazole resistance can involve an alteration in the target enzyme 14-alpha demethylase (change in binding site or over expression of the enzyme) or enhanced drug efflux caused by plasma membrane transporters. Many strains have developed multiple resistance mechanisms.

Candidaspecies have adapted several mechanisms of fluconazole resistance. This illustration shows an alteration in the target enzyme 14 alpha-demethylase (change in binding site or over expression of the enzyme) or from enhanced drug efflux caused by plasma membrane transporters.

Candida species have adapted several mechanisms of fluconazole resistance. This illustration shows enhanced drug efflux caused by plasma membrane transporters. The net effect of the efflux pump is to decrease the intracellular concentration of fluconazole.

This table is based on recommendations in: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Mucocutaneous candidiasis. May 7, 2013.

Source: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. May 7, 2013.

Epidemiology and Risk Factors

During the 1980s and 1990s, numerous reports emerged describing the development of refractory oropharyngeal candidiasis in AIDS patients following prolonged exposure to fluconazole (Diflucan).[1] The emergence of fluconazole-resistant candidiasis in HIV-infected persons correlated with the widespread use of fluconazole for oropharyngeal candidiasis during this time period. During the 1980s and 1990s, the percentage of fluconazole-resistant Candida species ranged from approximately 5 to 33%.[1,2] In addition, following the widespread use of fluconazole, the proportion of C. albicans isolates decreased and other Candida species, including C. krusei, C. dubliniensis, and C. glabrata, increased. Fluconazole-resistant oropharyngeal candidiasis has involved both C. albicans and the non-albicans species. From a clinical standpoint, treatment-refractory candidiasis is defined as signs and symptoms of candidiasis that persist for longer than 7 to 14 days after appropriate therapy.[3] Investigators have identified low CD4 cell count, advanced immunosuppression, greater number of fluconazole-treated episodes, and longer median duration of fluconazole therapy as the most important risk factors.[3,4,5,6] In more recent years, as a result of widespread use of potent antiretroviral therapy, clinicians have observed a major decrease in the frequency of oropharygeal candidiasis, esophageal candidiasis, and fluconazole-resistant candidiasis in patients with HIV infection.[3,7] Nevertheless, treatment refractory oropharyngeal candidiasis still occurs in approximately 5% of HIV-infected persons.[3]

Mechanisms for Fluconazole Resistance

Ergosterol is the predominant sterol in the fungal membrane and it serves as a bioregulator of fungal membrane fluidity and integrity.[8] The synthesis of ergosterol requires multiple steps and multiple enzymes (Figure 1). Fluconazole exerts its action on the fungal membrane by inhibiting the fungal cytochrome P-450 enzyme 14 alpha-demethylase, thereby blocking the conversion of lanosterol to ergosterol (Figure 2).[6] The inhibitory action of fluconazole causes depletion of ergosterol which in turn alters the fungal membrane structure and function. The inhibition of 14 alpha-demethylase also results in the build-up of lanosterol and other ergosterol precursors. The alterations in the fungal cell membrane eventually lead to fungal cell death. The selective action of fluconazole for fungal cell membranes occurs because human cells use cholesterol, not ergosterol, for the synthesis of cell membranes. The echinocandins have a mechanism of action distinct from the azoles: these agents inhibit fungal cell wall synthesis by blocking the production of 1,3-beta-D-glucan. Resistance to fluconazole can develop as a result of an alteration in the target enzyme 14 alpha-demethylase (change in binding site or over expression of the enzyme) (Figure 3) or from enhanced drug efflux caused by plasma membrane transporters (Figure 4).[6,7,9,10,11] Many of the strains of fluconazole-resistant Candida species display multiple mechanisms of resistance.[7]

Definition of Fluconazole Resistance

In 2012, the Subcommittee for Antifungal Testing of the Clinical Laboratory Standards Institute (CLSI) defined breakpoints for antifungal agents active against Candida species. Isolates with a fluconazole MIC greater than 8 mcg/ml are classified as resistant.[12] Primary fluconazole resistance is defined as resistance in the absence of prior fluconazole exposure. Secondary resistance occurs as a result of treatment with fluconazole. Clinical failure refers to persistence or progression of oropharyngeal candidiasis despite antifungal therapy. Factors that can affect clinical response include the immune status of the patient, adherence to antifungal therapy, and the potential presence of biofilms formed by Candida organisms.[6] Most patients who experience clinical failure with fluconazole will have Candida species isolates that show in vitro resistance to fluconazole.[6,13] In contrast, patients in whom fluconazole-resistant Candida is isolated will often still respond to fluconazole clinically.[14]

Prevention of Fluconazole-Resistant Candidiasis

Preventing fluconazole-resistant candidiasis is best achieved by avoiding unnecessary use of fluconazole or other systemic antifungal agents and by maximizing the patient's immune status with effective antiretroviral therapy.[15,16] In addition, most experts do not recommend chronic maintenance therapy following an episode of oropharyngeal candidiasis, or with recurrent episodes of oropharyngeal candidiasis.[15] Patients with cryptococcal meningitis or recurrent esophageal candidiasis require continuous fluconazole therapy, but systemic antifungal therapy can usually be avoided in patients with less advanced HIV disease and for less serious fungal infections.

Recommended Therapy for Fluconazole-Resistant Candidiasis

The Guidelines for Prevention and Treatment of Opportunistic Infections in Adults and Adolescents provides recommended preferred and alternative treatment options for fluconazole-refractory oropharyngeal and esophageal candidiasis (Figure 5).[3] These guidelines give the highest rating for posaconazole (Noxafil) oral suspension based on a study in which 75% of HIV-infected patients with azole-refractory oropharyngeal or esophageal candidiasis responded to posaconazole oral suspension (400 mg given twice daily for 28 days).[17] Itraconazole (Sporanox) oral solution is effective in about 50 to 65% of patients with refractory candidiasis when used at a dose of 100 to 200 mg per day.[11,18,19] The oral solution should be swished in the mouth and then swallowed, as it probably has some topical effect in addition to its systemic effect. In the largest trial involving itraconazole solution, 41 (55%) of 74 patients who failed fluconazole therapy (200 mg once daily) achieved a clinical response by day 28 when treated with itraconazole oral solution (100 mg bid), with 7 days as the median time to response.[19]The opportunistic infections guidelines do not provide a specific duration of therapy, but most experts would recommend at least 10 days of therapy for patients with fluconazole-refractory oropharyngeal candidiasis, with extension of the treatment course if the response is not complete at day 10. A number of effective intravenous options are considered options, including deoxycholate amphotericin B (Amphocin, Fungizone), amphotericin B lipid complex (Abelcet), liposomal amphotericin B (AmBisome), micafungin (Mycamine), caspofungin (Cancidas), anidulafungin (Eraxis), and voriconazole (Vfend).[19,20,21,22,23,24] Patients with esophageal candidiasis should generally receive a minimum of 21 days of therapy. In general, topical therapy for refractory candidiasis has not been effective. In ACTG Study 295, amphotericin B oral suspension was used as topical therapy for fluconazole-resistant candidiasis, but only 43% of the subjects responded by day 28.[25] Similarly, topical therapy with clotrimazole or nystatin has not usually produced good results. Clinicians have used low dose (0.3 mg/kg/day) intravenous amphotericin B for fluconazole-refractory oropharyngeal candidiasis with good success rates,[13] but intravenous amphotericin B has significant adverse effects, even when given at a lower dose.

Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Mucocutaneous candidiasis. May 7, 2013.